Sunday, May 31, 2009

I had started writing this a while back, and hadn't planned on putting it up today, but since my esteemed colleague over at the The Angry Pharmacist decided to talk about it today, I will too.

Regardless of what your government or insurance company tells you, e-prescribing is a pain in the ass. It is free for me to do it, but your unfortunate pharmacy is paying around 30 cents a script each time your doctor sends this crap over the internet.

It takes me, literally, 3-5 minutes PER DRUG to send this over the internet, with a decent high-speed DSL internet connection. As opposed to the 1 minute or less for me to neatly write it out, call in, or fax in.

The U.S. government is so enamored with this way to reduce efficiency and waste time that, starting 2 years ago, they began pressuring us to do this. In fact, Medicare pays us a small bonus to use it for Medicare patients. As a result, I am doing it too, because I can use the money. But that doesn't mean I like the system. I think the whole program should be cancelled and e-prescribing ditched.

But MOST frustrating to me is what happens when I have to do a controlled substance refill online. Yes, this group of drugs includes things like Methadone and Percocet, but also includes more pissy drugs like Lyrica and Ambien.

Here it is:

For refills on regular drugs: I have to click on "approve" or "disapprove". Simple enough.

For controlled drugs: I also have to click on "approve" or "disapprove".

BUT if I click on "approve" it says "This is prohibited by law. Click on the 'contact me' button to send a message to the requesting pharmacy that they need to request this from you by either means, i.e. fax or phone"

So I click on "contact me". Sounds benign, huh? But wait...

What then happens is that the pharmacy gets a message that ONLY says "Prescription denied by physician" (and they pay 30 cents for that). It doesn't say ANYTHING about actually trying to reach me by another method. I've personally verified this with 3 local pharmacies.

So the pharmacy tells my patient that I am the one at fault, because, after all, I refused to fill it (even though that isn't what I did). And so Mr. Patient gets angry, and calls my office pissed to yell at my staff and me.

What I don't understand is:

1. Why doesn't it actually tell them to contact me by another method (like it says it will)

2. WTF does it let them submit controlled requests online, WHEN IT ALREADY KNOWS I CAN'T REFILL THEM THAT WAY ANYWAY!!!

I'm now stepping down, putting my soapbox away, and shutting up, since my complaining won't matter at all to the bureaucrats who actually can change this.

(for those of you who recognized the source of this post's title, congratulations!)

As anyone in this field will tell you, the alcohol withdrawal (or "DT's" as we say in the medical biz) patients can be a nightmare or entertaining.

So while on call today, I got consulted to see a 60-something lady in DT's.

Unlike Mr. Pizza Guy DT, this lady was belting out Ethel Merman's greatest show tunes, at the top of her lungs! Thought she was in a show (which, technically, I guess she was. Me and a nurse as the audience, though when the room was empty she sang to the TV).

"THERE'S NO BUSINESS LIKE SHOW BUSINESS LIKE NO BUSINESS I KNOW!"

And finishing that one, she gave herself a round of applause, and went on to "Everything's Coming Up Roses", then "The Lullaby of Broadway". This has continued, as I wander on and off the floor doing consults. Later in the afternoon she switched to Barry Manilow, doing a surprisingly on-key rendition of "Copacabana".

They tried closing her door. It didn't do a thing. Her voice was in the gigadecibel range, and the use of duct tape is (unfortunately) forbidden.

At one point a security guard with the hospital's patrol K-9 wandered by. The dog stopped outside the door and began howling along.

Saturday, May 30, 2009

I'm on call again today. In fact, I'm on next weekend, too. For those of you who don't remember how much I LOVE being on call, click here.

Anyway, many wonder where we medical people get our stamina from. Is it an IV Red Bull drip? Is it our nerves of steel? Is it metal clamps applied to sensitive regions of our bodies?

Nope. It's caffeinated beverages and the need to eliminate them.

We all have our poisons. Mine are tea in the winter and Diet Coke in the summer. Many choose coffee. They keep us alert so that we may provide better service to you, our loyal customers. Equally important, however, is the tension that their consumption puts on our bladders. I mean, let's face it. It's hard NOT to be alert when you have to pee a lot, or desperately have to go. It's not like we can just run behind the nearest tree.

In medical school this became such a pre-test phenonemon that my roommate, Enzyme, actually made up a sign that said "PissFest-1989" after the first 2 tests in our M-1 year, and we left it there for the next 4 years. We thought about getting PissFest T-shirts made up, but since they were unlikely to get us girls we decided the effort wasn't worth it.

Wherever you are, Enzyme, I'm still thinking of your sign when I'm on call.

And now, back to the neurology floor. The victims (uh, I mean patients) await.

Thank you for coming in on this lovely Friday afternoon, ma'am. I guess you called around 1:30 today, and since we didn't have a 4:00, which is my last slot of the day, my secretary Mary put you in. Let me just open another Diet Coke, and we'll get started.

So you've had headaches for the past 20 years? And never seen a doctor before for them? What made you come in today, of all days, for this? Oh, you did a Google search.

Thank you for this printout of all the horrible types of brain tumors and aneurysms that can cause headaches and kill people. I appreciate it, because as a board certified neurologist with over 10 years of experience I really have no idea what sorts of things can cause headaches.

If you'd read it you might have noticed that the average survival from these awful things is 1-2 years, not 20. But I'm sure you're busy and didn't have time to actually read the articles you were printing up. After all, you had your hands full calling every neurologist on your insurance plan trying to find one who still had openings on this lovely Friday afternoon.

Of course we can get an MRI. I understand it would make you feel better, and allows me to cover my own legal butt, too.

Oh, you're claustrophobic? No, an MRI is really the best test we have right now for evaluating this sort of thing. I'm sorry that Reader's Digest somehow gave you the impression that I had a gadget in my office I could wave over you to make sure everything is okay, but I don't. Dr. McCoy borrowed my tricorder a while back and hasn't returned it yet. But we can do the MRI with Valium to relax you, if such a thing is possible.

I'll have my staff schedule the test for next week. No, I'm sorry. It's now 4:00 on a lovely Friday afternoon. Your insurance company requires an MRI request to be approved by a panel of dart-throwing chimpanzees before agreeing to pay for one. All of their offices are in another time zone, and have closed by now on this lovely Friday afternoon.

You really feel you need it immediately? Then the only thing I could suggest would be to go to an ER, and tell them you need an MRI right now. I'm sure, that after hearing your story and realizing how urgent this is, as opposed to a guy with chest pain, the ER doc will be happy to waste (uh, I mean spend) time and money on your case. Just don't tell him that I'm your doctor.

Oh, I had no idea your ER co-pay was so high. $50 does seem a bit extravagant for a lady with diamond rings on every finger and Porsche keys hanging out of your LV purse. I certainly can understand your refusal to go there.

Then it will have to be next week. My staff will call your insurance first thing Monday morning to get this authorized and scheduled.

Your insurance coverage runs out at the end of this month? My calender shows that today, May 29, is a Friday (which is a lovely afternoon by the way) and the last workday of the month. So Monday will be June, and we won't be able to get the MRI from your current insurance then, since it will have run out.

What insurance will you have on Monday? I'm sorry, I'm not contracted with that plan. I can send your internist a letter asking him to order the MRI. Oh, he's not contracted with it either. I see.

Yes ma'am, I agree it was entirely unreasonable of Mary to not have foreseen that you'd be changing to an insurance I don't take next week. You didn't mention that to her when you called for this appointment a few hours ago, but she really should have known, anyway. I'll discuss her suboptimal psychic powers with her at her next job evaluation in 2018.

I'm sorry you have to go already. Well, try to take it easy over the weekend, and I'll send my records to a neurologist on your next insurance, so they can help you out.

Going to a hockey game tonight sounds like fun, and it's great that you have such good seats. That looks like a nice air horn in your purse. I'm sure that sort of quiet, relaxed environment will help improve your headaches in the meantime. Thank you for sharing this lovely Friday afternoon with me.

Friday, May 29, 2009

I like most of my drug reps. I'm sure many medical people will be horrified at me saying that, but it's true. Most of them are decent people, working hard to support their families, just like I work hard to support mine. They have their job and I have mine. No, I'm not getting TV's, trips to Tahiti, or even a cheap pen to say that. It's just true in my experience.

HOWEVER it only takes a few bad ones to give them all a horrible name. I've had my share of bad ones. My current nightmare is Rikki Phoneysmile, who works for Giant Pharma, Inc. This company is known for teaching it's reps to be aggressive and obnoxious, and quickly eliminates reps who actually try to be friendly and well-mannered.

Rikki is a serious pain in the ass. My staff knows to not even ask me if I need anything from her. They just tell her I need none of her samples, and to go away. I keep hoping that if she goes long enough without my signature Giant Pharma, Inc. will demote her to their farm team at the used car lot.

Anyway, today Mrs. Grumpy e-mailed me to get some tomatoes on the way home (off the subject, I have no idea where all these tomatoes are going. She has me pick up tomatoes all the damn time, and I've never seen one on the dinner table in any form). So I stopped at the grocery store.

I'm standing in produce, fondling the tomatoes, when I'm suddenly assaulted by Rikki Phoneysmile! Out of the blue, she's suddenly in my face, between me and my tomato, extolling the virtues, mechanism of action, and low incidence of adverse effects seen with Flatulata, the latest unneeded product from Giant Pharma, Inc.

Rikki has actually, I shit you not, left a shopping cart with 2 small children (oh crap, she's breeding) and her purse in it, about 25 feet away, so she could come capitalize on her chance encounter with your's truly. She even whips out a signature pad, asks me to sign, and says she'll be happy to get me some Flatulata samples out of her trunk.

I frantically looked around for a cop, or someone having a stroke I could run to help, or a judge who could issue me a restraining order on the spot. No such luck. Just a lot of people staring at me and Rikki.

So I said "can you hold this for me?" and handed her the tomato. She automatically reached for it. And I ran out of the store.

Mrs. Grumpy isn't happy about the lack of tomatoes for her arcane purposes. But I consider that the lesser of the two evils.

Thursday, May 28, 2009

I have a nice young lady in my practice who, as far as I can tell, has only made one major mistake in life. She fell in love with, married, and had kids with Mr. Dumb. He later decided he'd rather be a crackhead, and dumped his family in favor of the excitement of living on the street and smoking crack.

So Miss Nicelady heroically soldiers on, dealing with single Mom stuff. She was awarded child support from Mr. Dumb. Unfortunately, this only gets withheld from his paycheck on the rare occasion he's actually working. So it amounts to $20-$30 once every few months, when he finds temporary work as a dishwasher.

So at her appointment today I asked her how things were going. She paused, and then began laughing.

2 months ago she suddenly began getting steady money from his child support withholding- $100 or so every 2 weeks. She was thrilled, and didn't want to look a gift horse in the mouth.

Until one night, some guy she'd never heard of called to see why she was stealing HIS money!

Wednesday, May 27, 2009

A guy comes in today, signs in, and sits down in the waiting room. Mary, my secretary, checks the sheet and comes back to me. He doesn't have an appointment today. How do I want her to handle this?

So she starts talking to him. He insists he has an appointment today, and to prove it he pulls out an appointment card. On a crumpled card, in Mary's handwriting, it says "Next appointment: May 27, 2008"

So Mary checks the schedule. Sure enough, he had an appointment on that day. Which, of course, he no-showed. And hasn't been here since.

So we tell him he's a year late for his appointment (which is a record for my practice), and offer to reschedule him (we're swamped today).

So what does he do? He gets pissed off (in front of my full waiting room) that we won't see him today.

It's been 20 years, maybe more, since I last saw the Rocky Horror Picture Show (yes, folks, in my younger days I was a Feature Creature). Anyway, at some point the computer picked the movie soundtrack, and began playing it.

And it dug up my old memories. So, without thinking, I began yelling out the old responses, just like I did at the movie.

I didn't even realize what I was doing until I looked up to see my staff were all standing in my office doorway, trying to figure out if they should call a neurologist, or psychiatrist, or Dr. Kevorkian.

Sunday, May 24, 2009

My cell phone rings at 12:09 a.m. on this Sunday morning, waking me from a dead sleep. I recognize the caller ID number, which is a bad sign already. It's Mr. Bozohusband. He and his wife are notorious for pointless phone calls.

Dr. Grumpy: "This is Dr. Grumpy."

Mr. Bozohusband: "Hi, I have a question about my wife's medications."

Dr. Grumpy: "What's up?"

Mr. Bozohusband: "She had dental surgery 2 days ago, and the dentist gave her Vicodin. Is it safe for her to take?"

Dr. Grumpy: "Hasn't she taken Vicodin for years for her back pain? She's never had any problems with it before."

Mr. Bozohusband: "No, she hasn't. But this is for her dental surgery, not her back pain."

Friday, May 22, 2009

Part of taking a patient's story down is getting a family history. This is often skipped by docs in a hurry, but can be quite helpful in looking for the odd genetic disorder. So I still try to do it on each new patient.

Sometimes, though, you can get some mighty weird answers. So, to help you enjoy the 3 day weekend, here are a few from my archives.

"My mom had diabetes, but only when she was alive."

"Both my grandmothers got menopause. My mom may have it, too."

Dr Grumpy: "Any major illnesses in your family?"Mr. Bozo: "No, but my Dad was a Lieutenant".

"My mom died of liver cirrhosis. Nobody knows how she got it, because she never smoked a day in her life."

"My brother has diabetes. I think it's gestational diabetes."

"My mom is 80 and healthy as a horse, except for her lung cancer."

"My grandparents were from Norway, or maybe Germany, or it could have been England. You know, one of those Russian countries."

"My parents are both fine, but my goldfish has been sick."

"My father died of uterine cancer".

"Family illnesses? Hell, Doc, I don't even know my Mom's last name anymore. She changes it all the fucking time".

My 11:00 was a migraine patient who refuses to take medications, or Botox, or do anything else I have to offer for her migraines. Fine, that's her decision.

Yet, she keeps coming back to me to complain about them!

So today she brought her mother to the appointment. After reviewing (yet again) all the commonly used migraine treatments, the patient again refused them.

So then Mom starts yelling at me! "You are incompetent! You are a fool! You should be able to fix my beautiful daughter's migraines! I see her suffering every day!"

When I pointed out that I'd offered several treatments for migraines, and her daughter had refused all of them, she got even angrier! "That has nothing to do with why she is suffering! You are trying to change the subject!"

Then they both got up and walked out. Mom said she's going to take beautiful daughter to see "a real doctor!".

Thursday, May 21, 2009

For the record, I'm not in Cincinnati. In fact I'm nowhere near it. I am easily one LONG day's drive from there, maybe more. Keep this in mind. I have nothing against Cincinnati, or anyone living there, but I am not even close to the place. I've never been there.

So today, for no apparent reason, a guy (not even a patient) calls my office. Because of his yelling at my secretary I decided to set down my Diet Coke, get on the phone, and deal with him myself (most docs hide from confrontation- when I'm in the right mood I'll go looking for it).

Wednesday, May 20, 2009

As I am typing this (they think I'm working on the chart) the couple across from me is actually fighting- and I mean swearing, cursing, and yelling at each other- over WHICH OF THEM DRINKS THE MOST WATER EACH DAY!!!

To make some extra money I do market research here and there. So last night I had a meeting on a new stroke drug.

I (male and over 6') walked into the market research place. The front counter was staffed by a teenage guy in a Black Sabbath T-shirt, who was reading a comic book and mumbling into a cell phone. When I signed in he asked me (I swear!):

"Dude, are you here for the doctor's meeting, or the survey on feminine hygiene products?"

Sunday, May 17, 2009

After returning from my exciting hour at the hospital, I decided to indulge in that perennial hobby of modern America- namely, trying to lose a few pounds.

So I got out the Wii Fit, chased the kids away from the TV (if I don't, they watch me exercise, like some sort of studio audience from hell, and make sarcastic comments).

I did some strength training exercises, as demonstrated by the Wii Fit trainer. For those of you don't have a Will Fit, this is a buff-looking computer animated trainer, male or female, that demonstrates exercises and tries to give you encouragement.

At one point, while balancing on one leg, I fell off and twisted my ankle. I'm lying there on the floor, in pain, holding it and trying to figure out if I broke something.

And while I'm lying there clenching my teeth, the Wii Fit trainer suddenly notices my weight is no longer on the balance board, and starts talking smack! "Hello? Are you still there? Where did you go? Your muscles aren't going to train themselves, you know!"

Without even thinking, and clouded with pain, I yelled "Shut the F--K up you digital a**hole!!!"

I looked up to see all 3 kids staring at me in shock. And Mrs. Grumpy looking REALLY pissed. All 3 dogs immediately ran away down the hall, realizing that this was NOT a good time for them to take my side.

I got woken up this lovely Sunday to do a hospital consult. So I slugged down a Diet Coke and dragged myself in.

It was a guy in alcohol withdrawal (or "DT's" as we say in the medical biz).

Normally I'm used to these guys seeing bugs or animals crawling all over, but today I got something, uh, different.

I went into the patient's room. He was tied down to the bed (they usually are until they start to clear).

He thought he was at a pizza joint!

He offered me pizzas of various types, thick and thin crust, various toppings. As we talked he flirted with an imaginary waitress and spoke to imaginary friends that were going in and out of the restaurant.

He also kept asking if someone would bring him some Parmesan cheese and (of course) another pitcher of beer.

Thursday, May 14, 2009

Alright, so I saw a guy 9 years ago, when I worked for (or was enslaved by) a different practice. I haven't seen him since I left there in 2000.

He called my office today to make an appointment, so my secretary was getting his info. As it turned out I'm not contracted with his current insurance.

So does he cancel the appointment to go elsewhere? Does he ask what my cash pay rates are?

NO! He begins SCREAMING at my secretary over the phone! And I mean SCREAMING! I was up front faxing stuff, and I could hear him yelling from 15 feet away, over the clatter of the fax machine!

He was, I swear, claiming that the doctor-patient relationship is a lifelong binding contract, and that I am legally obligated to see and treat him free of charge for the rest of his life (or mine, I guess).

I got on the phone to calm him down. Didn't work. Instead, he told me he is going to sue me for not taking his insurance.

I thanked him for calling and hung up. You can't reason with the unreasonable.

Saturday, May 2, 2009

I only do this one weekend per month, and it's the most miserable 63 hours of existence. After 10 years you'd think I'd be used to it, but I hate it even more now.

Yes, I am whining. I suppose I should be grateful for a job, etc., etc., etc.

My practice has reached a point where I don't really need to take hospital call for other neurologists, but I do it for 3 reasons:

1. Habit.2. Money.3. To get material for my blog.

Anyway, while driving in this morning, I thought of the old Weird Al Yankovic song "One More Minute", and how well it sums up my feelings about hospital call. So, with apologies to Weird Al, here are the slightly modified pertinent verses.

'Cause I'd rather spend eternity eating shards of broken glassThan spend one more minute on call

'Cause I'd rather get a hundred thousand paper cuts on my faceThan spend one more minute on call

I'd rather rip out my intestines with a forkThan listen to my damn cell phone ring againI'd rather slam my fingers in a doorAgain and again and again and again and again

Oh, can't you see what I'm tryin' to say, Darlin...

I'd rather have my blood sucked out by leechesShove an icepick under a toenail or twoI'd rather clean all the bathrooms in Grand Central Station with my tongueThan spend one more minute on call

Yes, I'd rather jump naked on to a huge pile of thumbtacksOr stick my nostrils together with crazy glueI'd rather dive into a swimming pool filled with double-edged razor bladesThan spend one more minute on call

I'd rather rip my heart right out of my ribcage with my bare handsand then throw it on the floor and stomp on it 'till I die...Than spend one more minute on call.

I wanted to embed the youtube video of the song, but due to copyright issues the embedding code has been turned off. But here's a link.

Welcome to my whining!

This blog is entirely for entertainment purposes. All posts about patients may be fictional, or be my experience, or were submitted by a reader, or any combination of the above. Factual statements may or may not be accurate.

Singing Foo!

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Note: I do not answer medical questions. If you are having a medical issue, see your own doctor. For all you know I'm really a Mongolian yak herder and have no medical training at all except in issues regarding the care and feeding of Mongolian yaks.